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Cardiovascular and pulmonary complications continue to account for major morbidity and mortality in patients undergoing noncardiac surgery. Emerging evidence-based practices dictate that the internist should perform an individualized evaluation of the surgical patient to provide an accurate preoperative risk assessment and stratification that will guide optimal perioperative risk-reduction strategies. This chapter reviews cardiovascular and pulmonary preoperative risk assessment, emphasizing the goal-directed management of patients at elevated risk for adverse cardiovascular outcomes in the perioperative period. In addition, perioperative management of diabetes mellitus and prophylaxis of endocarditis and for venous thromboembolism are reviewed.
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EVALUATION OF INTERMEDIATE- AND HIGH-RISK PATIENTS
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Simple, standardized preoperative screening questionnaires, such as the one shown in Table 467-1, have been developed for the purpose of identifying patients at intermediate or high risk who may benefit from a more detailed clinical evaluation. Evaluation of such patients for surgery should always begin with a thorough history and physical examination and with a 12-lead resting electrocardiogram, in accordance with the American College of Cardiology/American Heart Association guidelines. The history should focus on symptoms of occult cardiac or pulmonary disease. The urgency of the surgery should be determined, as true emergency procedures are associated with unavoidably higher morbidity and mortality risk. Preoperative laboratory testing should be carried out only for specific clinical conditions, as noted during clinical examination. Thus, healthy patients of any age who are undergoing elective surgical procedures without coexisting medical conditions should not require any testing unless the degree of surgical stress may result in unusual changes from the baseline state.
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PREOPERATIVE CARDIAC RISK ...